An Integrated Cancer Prevention Strategy: the Viewpoint of the Leon Berard Comprehensive Cancer Center Lyon, France

This article describes some of the key prevention services in the Leon Berard Comprehensive Cancer Center (CLB) Lyon, France, which are based on clinical prevention services, outreach activities, and collaboration with professional and territorial health communities. In addition, research is embedded at all stages of the prevention continuum, from understanding cancer causes through to the implementation of prevention interventions during and after cancer. Health promotion activities in the community and dedicated outpatient primary cancer prevention services for individuals at increased risk have been implemented. The CLB's experience illustrates how prevention can be integrated into the comprehensive mission of cancer centers, and how in turn, the cancer centers may contribute to bridging the current fragmentation between cancer care and the different components of primary, secondary, and tertiary prevention. With increasing cancer incidence, the shift toward integrated prevention-centered cancer care is not only key for improving population health, but this may also provide a response to the shortage of hospital staff and overcrowding in cancer services, as well as offer opportunities to reduce carbon emissions from cancer care.

[Shared decision-making: ethical issues]

SHARED DECISION-MAKING

ETHICAL ISSUES. Shared decision-making is a decision-making model and a model of interaction between healthcare professionals and healthcare users. Putting together medical-scientific data, experience, values and preferences of the caregiver on the one hand, and knowledge, needs, expectations, values andpreferences of the patient on the other, leads, if both parties wish so, to a discussion followed by a decision based on a common agreement. Cancer area, either in screening or treatment, in the curative or palliative phase, is well suited to shared decision-making. Shared decision-making is based on ethical principles and classical philosophical streams. Autonomy principle is in the foreground but must not become "an ethical injunction". The relationship between caregiver and patient should recognize above all ability and willingness to participate, or not, in decision-making. Key issues are those of mutual listening, uncertainty recognition and the role of emotions as powerful ethical levers.

[Facilitators and barriers to shared decision-making in France in 2021: National survey in cancer]

INTRODUCTION

Shared-decision making (SDM) combines clinical expertise of the healthcare professional with patient's knowledge, values and preferences. This survey explores from a patient perspective, the implementation, facilitators and barriers of SDM in oncology in France in 2021.

PATIENTS AND METHODS

From August to October 2021, the digital platform Cancer contribution conducted an online survey relayed by 11 patient associations.

RESULTS

Out of 916 responses, 727 were analyzed: 394 from patients with hematological malignancies [HM], 185 with breast cancer [BC], 93 with other solid tumors [ST] and 55 with multiple cancers [MC]. Among the participants, 47.2 % reported that they participated in a decision about their health management, with a significant variation according to the pathology (BC 43.8 %, HM 41.1 %, ST 57 %, MC 60 %, P=0.01), and regardless of age and gender. Two-thirds felt comfortable with the shared decision-making process, in relation with the time allocated and the information provided, regardless of the pathology. In addition, emotions, uncertainty and lack of information are the main reasons quoted by patients to explain their lack of ease in making a decision related to their health.

CONCLUSIONS

In this survey, less than half of the patients declared that they have been enrolled in a SDM approach, this rate varying according to the type of solid tumor or hematological malignancy. This study shows that to improve the implementation of SDM in routine clinical practice in cancer, sufficient time and use of decision aids are needed.

Implementation of shared decision-making and patient-centered care in France: Towards a wider uptake in 2022

We present the evolution of patient-centered care (PCC) and shared decision-making (SDM) in France since 2017, highlighting advantages and drawbacks of their implementation at the macro level. We then focus on several key policy and legislative milestones that are aimed to develop PCC and SDM. These milestones underline the importance of patient movements to support and fund the development of research and practice in the field. We shall conclude by presenting the growing research agenda and selected key topics. These key topics notably include the increase in both patient and healthcare professional trainings on PCC and SDM provided by healthcare users' and patients' representatives. PCC and SDM continue to be central preoccupations at the macro level, supported by public health policies and patients/healthcare users' actions. This overview, however, suggests that although implementation initiatives have increased since 2017, implementation remains scarce in routine clinical practice. Funding, not only for research projects, but for the implementation of PCC and SDM in real-life settings (e-decision aids, clinical guidelines integrating PCC/SDM, human resources dedicated to PCC/SDM, etc.) are needed to promote sustained adoption. More systematic training for both healthcare professionals and patients is also warranted for a true acculturation to occur.

Study protocol comparing the ethical, psychological and socio-economic impact of personalised breast cancer screening to that of standard screening in the "My Personal Breast Screening" (MyPeBS) randomised clinical trial

Background

The MyPeBS study is an ongoing randomised controlled trial testing whether a risk-stratified breast cancer screening strategy is non-inferior, or eventually superior, to standard age-based screening at reducing incidence of stage 2 or more cancers. This large European Commission-funded initiative aims to include 85,000 women aged 40 to 70 years, without prior breast cancer and not previously identified at high risk in six countries (Belgium, France, Italy, Israel, Spain, UK). A specific work package within MyPeBS examines psychological, socio-economic and ethical aspects of this new screening strategy. It compares women’s reported data and outcomes in both trial arms on the following issues: general anxiety, cancer-related worry, understanding of breast cancer screening strategy and information-seeking behaviour, socio-demographic and economic characteristics, quality of life, risk perception, intention to change health-related behaviours, satisfaction with the trial.

Methods

At inclusion, 3-months, 1-year and 4-years, each woman participating in MyPeBS is asked to fill online questionnaires. Descriptive statistics, bivariate analyses, subgroup comparisons and analysis of variations over time will be performed with appropriate tests to assess differences between arms. Multivariate regression models will allow modelling of different patient reported data and outcomes such as comprehension of the information provided, general anxiety or cancer worry, and information seeking behaviour. In addition, a qualitative study (48 semi-structured interviews conducted in France and in the UK with women randomised in the risk-stratified arm), will help further understand participants’ acceptability and comprehension of the trial, and their experience of risk assessment.

Discussion

Beyond the scientific and medical objectives of this clinical study, it is critical to acknowledge the consequences of such a paradigm shift for women. Indeed, introducing a risk-based screening relying on individual biological differences also implies addressing non-biological differences (e.g. social status or health literacy) from an ethical perspective, to ensure equal access to healthcare. The results of the present study will facilitate making recommendations on implementation at the end of the trial to accompany any potential change in screening strategy.

Trial registration

Study sponsor: UNICANCER. My personalised breast screening (MyPeBS). Clinicaltrials.gov (2018) available at: https://clinicaltrials.gov/ct2/show/NCT03672331

Contact: Cécile VISSAC SABATIER, PhD, + 33 (0)1 73 79 77 58 ext + 330,142,114,293, contact@mypebs.eu.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09484-6.

Impact of a health literacy intervention combining general practitioner training and a consumer facing intervention to improve colorectal cancer screening in underserved areas: protocol for a multicentric cluster randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer burden worldwide. In France, it is the second most common cause of cancer death after lung cancer. Systematic uptake of CRC screening can improve survival rates. However, people with limited health literacy (HL) and lower socioeconomic position rarely participate. Our aim is to assess the impact of an intervention combining HL and CRC screening training for general practitioners (GPs) with a pictorial brochure and video targeting eligible patients, to increase CRC screening and other secondary outcomes, after 1 year, in several underserved geographic areas in France.

METHODS

We will use a two-arm multicentric randomized controlled cluster trial with 32 GPs primarily serving underserved populations across four regions in France with 1024 patients recruited. GPs practicing in underserved areas (identified using the European Deprivation Index) will be block-randomized to: 1) a combined intervention (HL and CRC training + brochure and video for eligible patients), or 2) usual care. Patients will be included if they are between 50 and 74 years old, eligible for CRC screening, and present to recruited GPs. The primary outcome is CRC screening uptake after 1 year. Secondary outcomes include increasing knowledge and patient activation. After trial recruitment, we will conduct semi-structured interviews with up to 24 GPs (up to 8 in each region) and up to 48 patients (6 to 12 per region) based on data saturation. We will explore strategies that promote the intervention's sustained use and rapid implementation using Normalization Process Theory. We will follow a community-based participatory research approach throughout the trial. For the analyses, we will adopt a regression framework for all quantitative data. We will also use exploratory mediation analyses. We will analyze all qualitative data using a framework analysis guided by Normalization Process Theory.

DISCUSSION

Limited HL and its impact on the general population is a growing public health and policy challenge worldwide. It has received limited attention in France. A combined HL intervention could reduce disparities in CRC screening, increase screening rates among the most vulnerable populations, and increase knowledge and activation (beneficial in the context of repeated screening).

TRIAL REGISTRATION

Registry: ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

2020-A01687-32 . Date of registration: 17th November 2020.

What Works in Implementing Patient Decision Aids in Routine Clinical Settings? A Rapid Realist Review and Update from the International Patient Decision Aid Standards Collaboration

BACKGROUND

Decades of effectiveness research has established the benefits of using patient decision aids (PtDAs), yet broad clinical implementation has not yet occurred. Evidence to date is mainly derived from highly controlled settings; if clinicians and health care organizations are expected to embed PtDAs as a means to support person-centered care, we need to better understand what this might look like outside of a research setting.

AIM

This review was conducted in response to the IPDAS Collaboration's evidence update process, which informs their published standards for PtDA quality and effectiveness. The aim was to develop context-specific program theories that explain why and how PtDAs are successfully implemented in routine healthcare settings.

METHODS

Rapid realist review methodology was used to identify articles that could contribute to theory development. We engaged key experts and stakeholders to identify key sources; this was supplemented by electronic database (Medline and CINAHL), gray literature, and forward/backward search strategies. Initial theories were refined to develop realist context-mechanism-outcome configurations, and these were mapped to the Consolidated Framework for Implementation Research.

RESULTS

We developed 8 refined theories, using data from 23 implementation studies (29 articles), to describe the mechanisms by which PtDAs become successfully implemented into routine clinical settings. Recommended implementation strategies derived from the program theory include 1) co-production of PtDA content and processes (or local adaptation), 2) training the entire team, 3) preparing and prompting patients to engage, 4) senior-level buy-in, and 5) measuring to improve.

CONCLUSIONS

We recommend key strategies that organizations and individuals intending to embed PtDAs routinely can use as a practical guide. Further work is needed to understand the importance of context in the success of different implementation studies.

Cancer care at home or in local health centres versus in hospital: Public policy goals and patients' preferences in the Rhône-Alps region in France

In France, cancer treatments are mainly provided in hospitals, which are expensive and crowded. Health decision-makers therefore want to develop alternative structures such as home care and local health centres.

OBJECTIVES

To elicit cancer patients' preferences for home, local health centre, or hospital, and analyze factors affecting these choices: patients' characteristics, experiences of care, expectations and perceptions of cancer management.

METHODS

We developed a decision aid composed of 1) information on the 3 options 2) a questionnaire to measure preferences; 3) a questionnaire on sociodemographics and experiences of care, 386 patients participated in the survey.

RESULTS

hospital was the preferred option for 71 % of the participants, especially for complicated care, followed by home care (24 %) and local health centres (5%). Main reasons for preferring hospital were the wish to separate home life and place of care, wanting to avoid being a burden on their relatives. Reasons influencing a preference for home care were wanting to avoid trips, maintain their lifestyle, and finding hospitals frightening. Neither socio-demographics nor even experience of care seemed to explain preferences.

CONCLUSION

A quarter of patients preferred home care, which is highly disproportionate to the home care currently available. This suggests that hindrances to developing alternatives to hospital do not come from patients' reluctance to make use of them, but rather from healthcare providers' objections.

[Eliciting women’s preferences for breast cancer screening]

INTRODUCTION

Over the past decade, the balance between the benefits and harms of breast cancer screening (BCS) has been widely debated. To date, no French study has interrogated women's points of view and preferences (in the economic sense) for this controversial screening. This study aims to bridge this gap. We aimed to elicit women's trade-offs between the benefits and harms of BCS.

METHODS

A discrete choice experiment questionnaire was developed and administered by a survey institute to French women in order to elicit their preferences and trade-offs between the benefits and risks of BCS (i.e., overdiagnosis and false-positive mammography).

RESULTS

Eight hundred and twelve women, representative of the French general population (age, socioeconomic level, and geographical location), completed the survey. The women would be willing to accept on average 14.1 overdiagnosis cases (median = 9.6) and 47.8 women with a false-positive result (median = 27.2) to avoid one BC-related death. Results from our simulations predict that less than 50% of women would be willing to accept 10 overdiagnosis cases (respectively, 30 women with a false-positive mammography) for one BC-related death avoided.

CONCLUSION

Women are sensitive to both the benefits and harms of BC screening and their preferences are highly heterogeneous. Providing balanced information on both benefits and harms to women through an informed decision-making process would be more respectful of women's preferences.

Women's Benefits and Harms Trade-Offs in Breast Cancer Screening: Results from a Discrete-Choice Experiment

BACKGROUND

Over the past decade, the benefits and harms balance of breast cancer (BC) screening has been widely debated.

OBJECTIVES

To elicit women's trade-offs between the benefits and harms of BC screening and to analyze the main determinants of these trade-offs.

METHODS

A discrete-choice experiment with seven attributes depicting BC screening programs including varying levels of BC mortality, overdiagnosis, and false-positive result was used. Eight hundred twelve women aged 40 to 74 years with no personal history of BC recruited by a survey institute and representative of the French general population (age, socioeconomic level, and geographical location) completed the discrete-choice experiment. Preference heterogeneity was investigated using generalized multinomial logit models from which individual trade-offs were derived, and their main determinants were assessed using generalized linear models. Screening acceptance rates under various benefits and harms ratios were simulated on the basis of the distribution of individual preferences.

RESULTS

The women would be willing to accept on average 14.1 overdiagnosis cases (median = 9.6) and 47.8 false-positive results (median = 27.2) to avoid one BC-related death. After accounting for preference heterogeneity, less than 50% of women would be willing to accept 10 overdiagnosis cases for one BC-related death avoided. Screening acceptance rates were higher among women with higher socioeconomic level and lower among women with poor health.

CONCLUSIONS

Women are sensitive to both the benefits and the harms of BC screening and their preferences are highly heterogeneous. Our study provides useful results for public health authorities and clinicians willing to improve their recommendations of BC screening on the basis of women's preferences.

Decision aid on breast cancer screening reduces attendance rate: results of a large-scale, randomized, controlled study by the DECIDEO group

Controversies regarding the benefits of breast cancer screening programs have led to the promotion of new strategies taking into account individual preferences, such as decision aid. The aim of this study was to assess the impact of a decision aid leaflet on the participation of women invited to participate in a national breast cancer screening program. This Randomized, multicentre, controlled trial. Women aged 50 to 74 years, were randomly assigned to receive either a decision aid or the usual invitation letter. Primary outcome was the participation rate 12 months after the invitation. 16 000 women were randomized and 15 844 included in the modified intention-to-treat analysis. The participation rate in the intervention group was 40.25% (3174/7885 women) compared with 42.13% (3353/7959) in the control group (p = 0.02). Previous attendance for screening (RR = 6.24; [95%IC: 5.75-6.77]; p < 0.0001) and medium household income (RR = 1.05; [95%IC: 1.01-1.09]; p = 0.0074) were independently associated with attendance for screening. This large-scale study demonstrates that the decision aid reduced the participation rate. The decision aid activate the decision making process of women toward non-attendance to screening. These results show the importance of promoting informed patient choices, especially when those choices cannot be anticipated.

Treatment decision-making in the medical encounter: comparing the attitudes of French surgeons and their patients in breast cancer care

OBJECTIVES

To explore attitudes of French surgeons and their patients towards treatment decision-making (TDM) in the medical encounter.

METHODS

Surgeons involved in early stage breast cancer and their patients treated in a French cancer care network received a cross-sectional survey questionnaire containing examples of four different approaches to TDM: paternalistic, "some sharing", informed TDM and, shared TDM.

RESULTS

Surgeons' interaction styles were clearly distributed among paternalistic, shared and mixed. The paternalistic approach seemed to be associated with private rather than public practice and with less professional experience. Patients reported a rather low level of participation in TDM, varying by socio-demographic characteristics. One third of patients were dissatisfied with the way their treatment decision had been made.

CONCLUSION

Most surgeons reported adopting the "some sharing" approach. However, one patient out of three reported that they would have liked to participate more in the TDM process.

PRACTICE IMPLICATIONS

Surgeons need to ask patients what their preferences for involvement in TDM are and then think about ways to accommodate both their own and patients' preferences regarding the TDM process to be used in each encounter. In addition, decision aids could be offered to surgeons to help them discuss treatment options with their patients.

Heterogeneity of Cancer Patient Information-Seeking Behaviors

Objectives. This study aimed to determine whether cancer patients report different information-seeking behaviors (ISBs), investigate why they searched for information, and determine the relationship between their ISBs and their socioeconomic and behavioral characteristics. The authors also explored the relationship between ISB and participation in the medical decision-making process as well as the patients’ health state. Methods. A sample of 4270 French cancer survivors aged 18 or older was interviewed at 2 years following diagnosis. Rather than deciding a priori who should be considered an information seeker, the authors chose to statistically define the different ISBs using cluster analysis. Results. The authors identified 4 distinct profiles: Stereotypical high-information seekers and acquainted seekers are generally highly educated. They search for information due to their own motivation or because they are close to the medical profession. Constrained information seekers are characterized by a low socioeconomic status. They perceive themselves as “dropouts” of the health care system. Finally, the general information seekers did not systematically resort to any specific ISB. The authors show that after adjustment, belonging to a specific ISB was associated with the likelihood of participating in the medical decision-making process and, more surprisingly, with health state. Conclusions. A key finding of this study is that social disparities are significantly associated with the different ISBs. If these relationships are found in other samples, it would further support the need for medical teams to pay more attention to patients with lower levels of education, particularly in health care systems that have acknowledged equality as a founding principle. The clusters determined in this study offer a potential theoretical framework that can be used in future studies.

Shared decision making in the physician-patient encounter in France: a general overview in 2011

WHAT ABOUT POLICY REGARDING SDM? There is a social demand in France for more healthcare user information and greater patient participation in the decision making process, as reflected by the law of March 4(th) 2002 pertaining to patients' rights and the quality of the healthcare system known as the Law on Democracy in healthcare. WHAT ABOUT TOOLS - DECISION SUPPORT FOR PATIENTS? At the micro level, some research projects are being developed, some of them using decision aids. Preliminary results show that patients want to be informed but that the concept of shared decision making needs to be analysed and refined from both the patients' and the physicians' points of views. WHAT ABOUT PROFESSIONAL INTEREST AND IMPLEMENTATION? However, the relationship between physicians/healthcare professionals and patients/healthcare users is very complex and progress in this field takes time. Only ten years after enactment of the Law on Democracy in healthcare, it might be premature to try and determine the state of the art of shared medical decision making at the macro and meso levels in France. WHAT DOES THE FUTURE LOOK LIKE? There is room in France for further studies on shared decision making in the medical encounter. Researchers, decision makers, healthcare users and healthcare professionals need a place to meet and exchange. An observatory dedicated to shared decision making will be launched in the coming months, both at the national level and in collaboration with several other French-speaking areas like Switzerland and the province of Quebec.

Assessing the quality of decision support technologies using the International Patient Decision Aid Standards instrument (IPDASi)

Objectives

To describe the development, validation and inter-rater reliability of an instrument to measure the quality of patient decision support technologies (decision aids).

Design

Scale development study, involving construct, item and scale development, validation and reliability testing.

Setting

There has been increasing use of decision support technologies – adjuncts to the discussions clinicians have with patients about difficult decisions. A global interest in developing these interventions exists among both for-profit and not-for-profit organisations. It is therefore essential to have internationally accepted standards to assess the quality of their development, process, content, potential bias and method of field testing and evaluation.

Methods

Scale development study, involving construct, item and scale development, validation and reliability testing.

Participants

Twenty-five researcher-members of the International Patient Decision Aid Standards Collaboration worked together to develop the instrument (IPDASi). In the fourth Stage (reliability study), eight raters assessed thirty randomly selected decision support technologies.

Results

IPDASi measures quality in 10 dimensions, using 47 items, and provides an overall quality score (scaled from 0 to 100) for each intervention. Overall IPDASi scores ranged from 33 to 82 across the decision support technologies sampled (n = 30), enabling discrimination. The inter-rater intraclass correlation for the overall quality score was 0.80. Correlations of dimension scores with the overall score were all positive (0.31 to 0.68). Cronbach's alpha values for the 8 raters ranged from 0.72 to 0.93. Cronbach's alphas based on the dimension means ranged from 0.50 to 0.81, indicating that the dimensions, although well correlated, measure different aspects of decision support technology quality. A short version (19 items) was also developed that had very similar mean scores to IPDASi and high correlation between short score and overall score 0.87 (CI 0.79 to 0.92).

Conclusions

This work demonstrates that IPDASi has the ability to assess the quality of decision support technologies. The existing IPDASi provides an assessment of the quality of a DST's components and will be used as a tool to provide formative advice to DSTs developers and summative assessments for those who want to compare their tools against an existing benchmark.

[Patients' preferences and decision-making: state of the art and applications in cancer]

BACKGROUND

This paper deals with the physician-patient encounter. In France, the current legal framework allows patients to be informed (patients' rights to health information) and to participate to decisions regarding their own health. In such a context, this paper aims to give the reader the broad key components of the so-called 'patient treatment preferences elicitation process' in breast cancer, our research area.

METHODS AND RESULTS

We first present the general context, with a definition of the different physician-patient models. We then present decision aids, tools that aim to provide high-quality information to patients in the decision-making process. Finally, based on our previous studies and on examples drawn from the international literature, we present the empirical process of patients' preferences elicitation, which not only increases patients' knowledge of and satisfaction with the decision made, but also allows patients to be part of their disease management.

CONCLUSION

Far from being a phenomenon in the air supported by a legal system, this method developed in the 90s allows patients and more generally healthcare users to be autonomous without constraining them to a choice.

Shared decision-making in the physician-patient encounter in France: a general overview

In France, patients' claim for information and participation to medical decision-making was initiated in the eighties by AIDS associations, then reinforced by the tainted blood scandal and more recently by demands from cancer patients. The right to patient information was recognised on March 4th 2002 by the law pertaining to patients' rights and the quality of the healthcare system. The present article will explore this background by examining the bases, the current status and the development of shared decision-making in the physician-patient encounter in France. We will describe the evolution of the physician-patient relationship on the basis of legal and administrative documents, then show that patients' information, and more generally healthcare users' information, is a central concern for some national health institutions. Finally, we will demonstrate that even if the literature on shared decision-making is little developed in France as compared to other European countries, Northern America and Australia, some studies have nonetheless been conducted. Their results, combined with a legal context and national health institutions encouraging shared decision-making, should prompt otherwise reluctant healthcare professionals to implement this approach in everyday medical practice.

Shared decision making in the medical encounter: are we all talking about the same thing?

OBJECTIVE

This article aims to explore 1) whether after all the research done on shared decision making (SDM) in the medical encounter, a clear definition (or definitions) of SDM exists; 2) whether authors provide a definition of SDM when they use the term; 3) and whether authors are consistent, throughout a given paper, with respect to the research described and the definition they propose or cite.

METHODS

The authors searched different databases (Medline, HealthStar, Cinahl, Cancerlit, Sociological Abstracts, and Econlit) from 1997 to December 2004. The keywords used were informed decision making and shared decision making as these are the keywords more often encountered in the literature. The languages selected were English and French.

RESULTS

The 76 reported papers show that 1) several authors clearly define what they mean by SDM or by another closely related phrase, such as informed shared decision making. 2) About a third of the papers reviewed (25/76) cite these authors although 8 of them do not use the term in a manner consistent with the definition cited. 3) Certain authors use the term SDM inconsistently with the definition they propose, and some use the terms informed decision making and SDM as if they were synonymous. 4) Twenty-one papers do not provide or cite any definition, or their use of the term (i.e., SDM) is not consistent with the definition they provide.

CONCLUSION

Although several clear definitions of shared decision making have been proposed, they are cited by only about a third of the papers reviewed. In the other papers, authors refer to the term without specifying or citing a definition or use the term inconsistently with their definition. This is a problem because having a clear definition of the concept and following this definition are essential to guide and focus research. Authors should use the term consistently with the identified definition.

Seeking a second opinion: Do patients need a second opinion when practice guidelines exist?

INTRODUCTION

Patients often search for a second opinion (i.e., a search for additional information on the diagnosis and/or treatment options and the potential prognosis, which will help the patient decide what to do or not to do, where, with whom and how). The scope of this phenomenon is not well documented. Also it is not clear if this is warranted or not. This paper aims to explore whether knowing that his clinician follows practice guidelines eliminates the need of a patient's to seek a second opinion. Given that practice guidelines should allow each patient to benefit from the best current clinical evidence, one might wonder if in such a context a second opinion is still necessary, and if so, for what reasons?

METHODS

We review the literature to find the reasons that may prompt a patient to seek a second opinion before the implementation of practice guidelines. We then analyse, from a conceptual point of view, whether for 'informed patient' (i.e., one who knows about and understands practice guidelines) these reasons still hold after the implementation of practice guidelines and if new reasons for seeking a second opinion have emerged. We also discuss practical limitations to searching for a second opinion.

RESULTS

We show that even if some reasons, like the search for a second opinion to check whether the treatment prescribed by the first physician is appropriate or not, can be questioned after the implementation of practice guidelines, an 'informed patient' may still wish to seek a second opinion stemming from new reasons which have emerged after the introduction of practice guidelines, e.g., to determine which practice guidelines his physician follows and whether they are appropriate to his case.

SUMMARY AND CONCLUSION

We conclude that the implementation of practice guidelines will not eliminate the need for a second opinion consultation. On the contrary, the use of guidelines can even stimulate a broader request for second opinions. This conclusion however needs to be validated in an empirical study.

Developing a quality criteria framework for patient decision aids: online international Delphi consensus process

OBJECTIVE

To develop a set of quality criteria for patient decision support technologies (decision aids).

DESIGN AND SETTING

Two stage web based Delphi process using online rating process to enable international collaboration.

PARTICIPANTS

Individuals from four stakeholder groups (researchers, practitioners, patients, policy makers) representing 14 countries reviewed evidence summaries and rated the importance of 80 criteria in 12 quality domains on a 1 to 9 scale. Second round participants received feedback from the first round and repeated their assessment of the 80 criteria plus three new ones.

MAIN OUTCOME MEASURE

Aggregate ratings for each criterion calculated using medians weighted to compensate for different numbers in stakeholder groups; criteria rated between 7 and 9 were retained.

RESULTS

212 nominated people were invited to participate. Of those invited, 122 participated in the first round (77 researchers, 21 patients, 10 practitioners, 14 policy makers); 104/122 (85%) participated in the second round. 74 of 83 criteria were retained in the following domains: systematic development process (9/9 criteria); providing information about options (13/13); presenting probabilities (11/13); clarifying and expressing values (3/3); using patient stories (2/5); guiding/coaching (3/5); disclosing conflicts of interest (5/5); providing internet access (6/6); balanced presentation of options (3/3); using plain language (4/6); basing information on up to date evidence (7/7); and establishing effectiveness (8/8).

CONCLUSIONS

Criteria were given the highest ratings where evidence existed, and these were retained. Gaps in research were highlighted. Developers, users, and purchasers of patient decision aids now have a checklist for appraising quality. An instrument for measuring quality of decision aids is being developed.

[Patient treatment preferences elicitation process: a French perspective]

This paper deals with the physician-patient encounter. In France, the current legal framework allows patients to be informed (patients'rights to health information) and to participate to decisions regarding their own health. In such a context, this paper aims to give the reader the broad key components of the so-called 'patient treatment preferences elicitation process'in breast cancer, our research area. We first present the general context, with a definition of the different physician-patient models. We then present decision aids, tools that aim to provide high-quality information to patients in the decision-making process. Finally, based on our previous studies and on examples drawn from the international literature, we present the empirical process of patients'preferences elicitation which not only increases patients'knowledge of and satisfaction with the decision made, but also allows patients to be part of their disease management. Far from being a phenomenon in the air supported by a legal system, this method developed in the 90s allows patients and more generally healthcare users to be autonomous without constraining them to a choice.

[Knowledge and preferences of the patients about medical information: a study on 700 patients in a regional comprehensive cancer centre]

Information is an important part of the patient care in oncology. The role and objectives of patient information were determined by a law passed in March 2002. This study investigates the knowledge of the patients about their rights and their views on what they consider most important. Information about health status and treatments is considered a priority (92.8% of respondents). The majority of patients whish to be given every information about their disease and treatments. On the contrary only 6.7% would rather receive less precise information tailored to what they want to know. Keeping control on the communication of their health information to relatives and other doctors is the option preferred by the majority of patients. Fifty two per cent of the persons are reluctant to be given medical information on the telephone. However opinions differ among social classes since 62% of patients from the upper classes consider it positively. This study demonstrates that the 2002 law is, in its broad outlines, a good response to patient's information needs.

Clinical issues in shared decision-making applied to breast cancer

OBJECTIVES

To assess (1) the clinical issues addressed during the medical encounter; (2) the feasibility of the process of shared decision-making in clinical practice and (3) patients' desires concerning the question of 'who should take the decision in breast cancer treatments?'

DESIGN

Qualitative pilot study based on clinical encounters using decision boards and information booklets.

SETTING

Centre Léon Bérard, a comprehensive cancer centre in the Rhône-Alpes region of France.

PARTICIPANTS

One breast cancer surgeon and 22 breast cancer patients.

MAIN OUTCOME MEASURES

Analysis of patients' reactions to a shared decision-making process concerning surgery and chemotherapy, and analysis of its practical feasibility (i.e. duration of the consultations).

RESULTS

(1) Twenty-one patients participated in the decision regarding surgery; all chose conservative treatment; 15 patients had their own say about chemotherapy (nine chose no chemotherapy, six chose chemotherapy). (2) Participating in treatment choice generated anxiety for a majority of patients. Some were dissatisfied because they had to make a choice and consequently to give up the other option. Finally, some were uncertain about making the right choice. Nevertheless, most were satisfied with the information given and the possibility of participating to the treatment decision-making process. (3) The total duration of the entire process of shared decision-making is consistent with the time spent with patients with such a severe disease.

DISCUSSION/CONCLUSION

Most of the patients expressed their satisfaction regarding the possibility to participate in treatment decision-making, knowing that offering treatment choice is very unusual in France. From this pilot study it appears that shared decision-making is feasible in clinical practice. Nevertheless, a quantitative study based on a large sample of patients is necessary to: (1) confirm this hypothesis, (2) ensure that patients are willing to participate in their treatment decision-making, and (3) measure the potential benefits related to this participation.

Elaborating patient information with patients themselves: lessons from a cancer treatment focus group

OBJECTIVE

To assess the significance of patients' input in the elaboration of a patient information booklet.

DESIGN

Qualitative study based on focus group discussions.

SETTING

Centre Léon Bérard, a comprehensive cancer centre in the Rhône-Alpes region of France.

PARTICIPANTS

(1) A multidisciplinary working group (oncologists, health economists and one clinical psychologist) wrote up initial information documents concerning possible breast cancer treatments. (2) A focus group comprised of patients with a history of breast cancer and healthy volunteers discussed their reactions to these documents.

MAIN OUTCOME MEASURE

Analysis of the focus group's reactions according to key themes predetermined by the working group and related themes introduced by the focus group itself.

RESULTS

The focus group proposed numerous, significant modifications to answer requests for additional information, clarification and better readability in the information booklets.

DISCUSSION/CONCLUSIONS

This qualitative analysis showed a significant input of patients' perspective in the elaboration of patient information. It is also an additional support to the feasibility and appropriateness of the focus group technique. The next stage will be to test whether information documents produced here conform to the needs of patients currently undergoing treatment.